Interference Screw Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: Part 2

Nurmi, Janne T.; Kannus, Pekka; Sievänen, Harri; Järvelä, Timo; Järvinen, Markku; Järvinen, Teppo L. N.

doi:10.1177/0363546503261703

Cited by 60 publications

(97 citation statements)

References 38 publications

(77 reference statements)

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“…Based on a comparison between graft tension at the end of preconditioning and graft tension 30 min after application of initial tension, preconditioning decreased the tension loss due to relaxation, which is similar to previous findings. 10,11 Previous studies have recorded larger tension losses for patella tendons than the current study. Previously, primate patella tendons were relaxed for 10 min following 10 min of static preconditioning to a maximum load of 50 N. 17 The average tension decreased by 31%, compared to 21% over the same time period for the current study.…”

Section: Discussionmentioning

confidence: 44%

“…12 A previous study performed with quadruple strand hamstring tendon grafts used a reference point recorded following 100 s of isometric loading, and showed a 58% decrease in tension over the next hour. 10 For the current study, hamstring tendon graft tension decreased 50% over the same time period. Based on a comparison between graft tension at the end of preconditioning and graft tension 30 min after application of initial tension, preconditioning decreased the tension loss due to relaxation, which is similar to previous findings.…”

Section: Discussionmentioning

confidence: 60%

“…Following reconstruction, viscoelastic relaxation decreases the tension within a graft. Hamstring tendon grafts are typically preconditioned on a graft board at approximately 89 N [8][9][10][11] to minimize the tension loss. Two in vitro studies that mimicked preconditioning and application of initial tension determined that the tension within hamstring tendon grafts decreases by more than 50% within an hour.…”

mentioning

confidence: 99%

“…Two in vitro studies that mimicked preconditioning and application of initial tension determined that the tension within hamstring tendon grafts decreases by more than 50% within an hour. 10,12 Patella tendon grafts are not typically preconditioned outside the knee prior to reconstruction, presumably due to the belief that patella tendon grafts are less susceptible to relaxation. A 50% decrease in tension over 15 min has been measured for patella tendon grafts that were not preconditioned immediately prior to application of tension.…”

mentioning

confidence: 99%

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In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

Elias¹,

Surya²,

Ciccone³

2008

Journal Orthopaedic Research

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Following anterior cruciate ligament reconstruction, grafts relax and warm from the temperature of the operating room to body temperature. The current study compared graft tension and stiffness between patella tendon and hamstring tendon grafts. Six quadruple strand hamstring tendon grafts and six patella tendon grafts were preconditioned and loaded to 105 N while at 208C. Graft tension and stiffness were measured after 15 min, after an additional 4 h, and after increasing the temperature to 348C. A two-way repeated-measures analysis of variance and a post hoc test were used to compare the measurements between the two types of graft and identify significant ( p < 0.05) changes for each type of graft. Tension was significantly larger for the patella tendon grafts, although the stiffness values were not significantly different ( p > 0.8). For both types of graft, tension and stiffness decreased significantly with time and the temperature increase. The lowest tension and stiffness measurements were 50 AE 11 N and 129 AE 35 N/mm, respectively, for the patella tendon grafts, compared to 18 AE 5 N and 115 AE 11 N/mm, respectively, for the hamstring tendon grafts. Both types of graft lose tension to relaxation and a temperature increase, but the tension loss is larger for hamstring tendon grafts. Initial tension is applied to autografts used for anterior cruciate ligament reconstruction to limit postoperative knee laxity. Recommended initial tension levels range from 20 to 90 N for patella tendon grafts [1][2][3][4][5] and from 70 to 80 N 1,6,7 for hamstring tendon grafts. Following reconstruction, viscoelastic relaxation decreases the tension within a graft. Hamstring tendon grafts are typically preconditioned on a graft board at approximately 89 N 8-11 to minimize the tension loss. Two in vitro studies that mimicked preconditioning and application of initial tension determined that the tension within hamstring tendon grafts decreases by more than 50% within an hour.10,12 Patella tendon grafts are not typically preconditioned outside the knee prior to reconstruction, presumably due to the belief that patella tendon grafts are less susceptible to relaxation. A 50% decrease in tension over 15 min has been measured for patella tendon grafts that were not preconditioned immediately prior to application of tension.13 As the graft tension decreases, the stiffness needed to maintain knee stability increases.14 The stiffness of hamstring tendon grafts has been shown to decrease as the tension decreases. 12 The relationship between stiffness and tension has not been determined for patella tendon grafts.Graft tension and stiffness can also decrease due to an increase in temperature. Autografts typically cool to the temperature of the operating room prior to implantation in the knee and warm to body temperature postoperatively. Following complete relaxation, an increase in temperature from operating room to body temperature has been shown to decrease the tension and stiffness of hamstring tendon grafts by approximately...

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Section: Discussionmentioning

confidence: 44%

Section: Discussionmentioning

confidence: 60%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

Elias¹,

Surya²,

Ciccone³

2008

Journal Orthopaedic Research

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“…11 Graft preconditioning is suggested to decrease the degree of stress relaxation following graft fixation 12 and thus potentially prevent the development of knee laxity. 13 However, there are conflicting reports about its efficacy, [11][12][13][14] and the optimal preconditioning and fixation tension required is undefined. 13 The contrasting reports may well be due to the variations in loading applied to the graft, but also due to the differences between individuals and specifically genders in terms of tendon properties.…”

mentioning

confidence: 99%

Effect of acute tensile loading on gender‐specific tendon structural and mechanical properties

Burgess

Graham-Smith

Pearson

2009

Journal Orthopaedic Research

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Stretching is commonly used prior to exercise, as it is thought to reduce the risk of injury, and it is also used in the preconditioning of tendon grafts. As tendon properties have been shown to be different between genders, it is proposed that stretching will differentially affect the structure. Here we examine the effect of acute stretch on the mechanical properties of both male and female medial gastrocnemius tendon. Female [20 years AE 1 (SEM), n ¼ 17] and male (22 years AE 1, n ¼ 18) subjects underwent a 5-min passive dorsiflexion stretch. Prior to and post stretch medial gastrocnemius tendon stiffness (K), length (l) and cross-sectional area (csa) were measured using ultrasonography and dynamometry. Stiffness and Young's modulus (e) were significantly reduced with stretch for both genders (p < 0.05). Females showed significantly (p < 0.05) greater pre-to poststretch decreases in K (22.4 vs. 8.8%) and e (20.5 vs. 8.4%) in comparison to males. The present results show that stretching acutely reduces stiffness of the medial gastrocnemius tendon in females and males, with females showing significantly greater change. The observed disparity between genders may be due in part to variations in tendon moment arm and intrinsic differences in tendon composition. These differential changes in tendon mechanical properties have functional, motor control, and injury risk implications, as well as possible implications for preconditioning of tendon grafts. ß

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Does a tensioning device pinned to the tibia improve knee anterior–posterior load-displacement compared to manual tensioning of the graft following anterior cruciate ligament reconstruction? A cadaveric study of two tibial fixation devices

2006

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Devices that are pinned to the tibia to tension an anterior cruciate ligament (ACL) graft produce joint reaction loads that in turn can affect the maintenance of graft initial tension after tibial fixation and hence knee anterior-posterior (AP) load-displacement. However, the effect of these devices on AP load-displacement is unknown. Our objectives were to determine whether tensioning by device versus tensioning by hand causes differences in AP load-displacement and intraarticular graft tension for two commonly used tibial fixation devices: a bioresorbable interference screw and a WasherLoc. AP load-displacement and intraarticular graft tension were measured in 20 cadaveric knees using a custom arthrometer. An initial tension of 110 N was applied to a double-looped tendon graft with the knee at extension using a tensioning device pinned to the tibia and a simulated method of tensioning by hand. After inserting the tibial fixation device, the 134 N anterior limit (i.e., anterior position of the tibia with respect to the femur with a 134 N anterior force applied to the tibia) and 0 N posterior limit (i.e., AP position of the tibia relative to the femur with a 0 N force applied to the tibia) were measured with the knee in 25 degrees flexion. Intraarticular graft tension was measured at extension. These limits and intraarticular graft tension were also measured after cyclically loading the knee 300 times. Compared to a simulated method of tensioning by hand, tensioning with a device pinned to the tibia did not decrease the 134 N anterior limit and did not cause posterior tibial translation. However, intraarticular graft tension was maintained better with a tensioning device pinned to the tibia for the Washerloc, but not the interference screw. For two commonly used tibial fixation devices, a tensioning device pinned to the tibia does not improve AP load-displacement at 25 degrees flexion over tensioning by hand when the graft is tensioned at full extension, but does improve the maintenance of intraarticular graft tension for the Washerloc.

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Interference Screw Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: Part 2

Abstract: Clinically applicable preconditioning protocols cannot eliminate the intrinsic viscoelasticity from ACL soft tissue grafts, and thus, the reasonableness of preconditioning per se is questioned in ACL reconstruction.

Cited by 60 publications

References 38 publications

In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

Effect of acute tensile loading on gender‐specific tendon structural and mechanical properties

Does a tensioning device pinned to the tibia improve knee anterior–posterior load-displacement compared to manual tensioning of the graft following anterior cruciate ligament reconstruction? A cadaveric study of two tibial fixation devices

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